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Heart Failure

Screening for Heart Failure using BNP

Within 1 hour of arrival:

Suspected Heart Failure (HF) If acute

History/examination inc. baseline observations (HR, BP, Temp, Resp Rate, Spo2, EWS, AVPU)

Investigations:

  • ECG - CXR - Urinalysis
Bloods:

  • FBC, Glucose, Arterial/Venous Blood Gases

 

Complete BNP Criteria Screening Tool

Patient Features & Score

  • SOB 1
  • Ankle oedema 2
  • Orthopnea 3
  • PND 3
  • Prev MI/ CAD 1
  • HBP 1
  • DM 1
  • AF 1
  • LBBB on ECG 2

 

Score of 3 or more or clinical suspicion of HF?

YES

If clinical diagnosis of active HF is clear and patient has historic diagnosis of HF, BNP is not necessary. Immediately refer to HF nurses by eReferral.

NO

Consider other diagnosis (end of pathway)

 

Perform BNP Test

BNP result provided 24/7 (pathology)

  • New onset atrial fibrillation, syncope, symptoms suggestive of recent
    ischaemia or arrhythmia
  • should prompt independent assessment of these conditions, otherwise;

    • BNP Guidance

    All echo requests ‘? LV function’ must meet BNP criteria (CIU) except shocked haemodynamically compromised patients - immediate echo indicated via on call cardiology SpR

     

    HFN Referral

    HFN will arrange ward review within 24 hours OR process OPC referral immediately.

    Go to Senior review (at Post Take Ward Round)

     

    Review BNP result

    Give consideration to:

    • New onset atrial fibrillation, syncope, symptoms suggestive of recent ischaemia or arrhythmia
    • should prompt independent assessment of these conditions, otherwise;

     

    < 100pg/ml - Heart Failure ruled out as cause of acute symptoms

    • BNP may be normal in very well controlled heart failure
    • Suggests ECHO is NOT indicated now
    • Admitting team consider alternative diagnosis
    • Continue management appropriate to new diagnosis

     

    100 - 400pg/ml - Heart Failure is likely

    • Patient is in a low risk category with regard to HF
    • Out patient investigation may be appropriate
    • Discharge remains a clinical judgement
    • Discharge may be possible if Heart Rate >50 OR <100, RR <24, BP >100 systolic
    Go to Senior review (at Post Take Ward Round)

     

    > 400pg/ml - Heart failure is considered very likely

    • Patient is in a higher risk category
    • BNP level correlates with risk
    • Inpatient investigation and management is often appropriate
    Go to Senior review (at Post Take Ward Round)

     

    Within 24 hours of admission:

    Senior review (at Post Take Ward Round)

    To include:

    • If discharge: Considered Heart Failure Clinic (HFC) / Heart Failure Diagnostic Clinic (HFDC)
    • If admission: Discussion on appropriate ward (i.e. Ward 19) based on primary condition

       

    Patient Suitable for discharge

    Discharge Checklist:

    • Add/ increase diuretic if oedema
    • Start/increase ACE inhibitor if not contraindicated
    • Advise on AF rate and BP control
    • Ask GP to check UE / review if Indicated
    • Ensure patient has been referred to:
    • HF Diagnostic Clinic (if new patient)
    • HF Clinic (if patient is known)
    Patient discharged

     

    Patient to be Admitted

    • Establish ceiling of treatment
    • Consider if patient fits criteria for Care for the Dying Person Plan

    Monitor

    • Full set of physiological observations (at least 4 hrly)
    • Fluid balance (at least 4 hrly)
    • Daily weight chart initiated (within 24 hrs)

    Ensure Management of:

    • Fluid overload (diuretics prescribed)
    • Renal dysfunction

    Repeat U&Es within 48 hours

    HF team will review patients with BNP >400 within 24 hours of BNP result

    ECHO performed within 48 hours of BNP

     

    Ensure daily body weight is monitored for duration of admission